Clinical UM Guideline PRODUCTION DATE
Total Page：16
File Type：pdf, Size：1020Kb
FINAL DRAFT – LOGO TO BE INSERTED UPON FINAL Clinical UM Guideline PRODUCTION DATE Subject: Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications Guideline #: CG-MED-87 Publish Date: 11/12/202002/18/20 21 Status: Revised Last Review Date: 11/05/202002/11/20 21 Description This document addresses the use of single photon emission computed tomography (SPECT) for non-cardiovascular indications. SPECT provides three-dimensional images of the concentration of a radiopharmaceutical within various tissues and organs, and is an established imaging modality for a number of different indications. Note: Please see the following related documents for additional information: CG-MED-77 SPECT/CT Fusion Imaging Clinical Indications Medically Necessary: SPECT scans are considered medically necessary for any of the following: 1. Bone and joint conditions—to differentiate between infectious, neoplastic, avascular or a traumatic process. 2. Brain tumors—to differentiate between lymphomas and infections such as toxoplasmosis particularly in the immunosuppressed, or recurrent tumor vs. radiation changes, when PET is not available. 3. Dopamine transporter (DaT) scan—when criteria (a) and (b) are met: a. To differentiate Parkinsonian syndromes associated with nigrostriatal degeneration from other disorders: i. To differentiate Parkinsonian syndrome from non-neurodegenerative disorders such as essential tremor or drug-induced tremor; or This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to implement a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only – American Medical Association Page 1 of 35 Clinical UM Guideline CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications ii. In individuals with dementia, to differentiate between Alzheimer disease and dementia with Lewy bodies; and b. The diagnosis is unclear and the results are likely to guide management. 4. Liver hemangioma—using labeled red blood cells to further define lesions identified by other imaging modalities. 5. Liver malignancies—to determine arterial hepatic perfusion as a component of selective internal radiation therapy (SIRT) or radioembolization treatment. 6. Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin. 7. Neuroendocrine tumors (for example, adenomas, carcinoid, pheochromocytomas, neuroblastoma, vasoactive intestinal peptide [VIP] secreting tumors, thyroid carcinoma, adrenal gland tumors)—using a monoclonal antibody (OctreoScan™ [Covidien, Hazelwood, MO]) or I-131 meta-iodobenzyl-guanidine (MIBG). 8. Parathyroid imaging. 9. Renal - Dimercaptosuccinic acid (DMSA) scan to assess the status of kidney for scarring and function. 10. SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate. 9. Not Medically Necessary: For noncardiovascular indications, SPECT scans are considered not medically necessary for all other purposes, including, but not limited to: 1. Attention Deficit and Hyperactivity Disorder. 2. Chronic fatigue syndrome. 3. Colorectal carcinoma (for example, used with the monoclonal antibody or IMMU-4 and CEA-Scan® [Immunomedics Inc., Morris Plains, New Jersey]). 4. Dopamine transporter (DaT) scan for all indications other than those listed as medically necessary. 5. Evaluation or management of cerebrovascular accident (CVA, stroke), subarachnoid hemorrhage, or transient ischemic attack. 6. Malignancies other than those listed as medically necessary. 7. Neuropsychiatric disorders without evidence of cerebrovascular disease. 8. Pervasive development disorders (PDD). This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to implement a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only – American Medical Association Page 2 of 35 Clinical UM Guideline CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications 9. Prostate carcinoma (for example, used with the monoclonal antibody ProstaScint® [EUSA Pharma, Langhorne, PA], with or without fusion imaging with computed tomography or magnetic resonance imaging). 10. Scintimammography for breast cancer. 11. SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate. Coding The following codes for treatments and procedures applicable to this document are included below for informational purposes.